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Ann Thorac Surg 1997;63:1372-1373
© 1997 The Society of Thoracic Surgeons
DR MARVIN POMERANTZ (Denver, CO): I congratulate Dr De Groot and his associates for this fine paper.
We have operated on 148 patients with MDR-TB. Our patients are not robust. Most of them have been on hyperalimentation and they are approximately 10 years olders than Dr De Groot's patients.
We obtain computed tomographic scans of all of our patients and perfusion scans of most. If pulmonary functions are good and there is only 15% remaining on the side to undergo lobectomy, a pneumonectomy will be performed to produce a cleaner operation.
Our operative approach is similar, with a serratus-sparing incision, and an extrapleural dissection when necessary. Eighty percent of Dr De Groot's pneumonectomies were left-sided. In our series 70% are left-sided. There is a definite predilection for left lung destruction with Mycobacterium tuberculosis.
We differ on the length of postoperative drug therapy. Doctor De Groot employs 8 months of postoperative therapy, whereas we continue drug therapy for 18 to 24 months. This results in a 90% cure rate compared with his 80%.
More than half of our patients are sputum positive at the time of operation. This is one of our major indications for the use of muscle flaps.
We have only had three bronchopleural fistulas: one was a technical error where the left main bronchus was too long, one was a parenchymal leak (eventually sealed), and the other was in our only patient operated on for massive hemorrhage whom we could never get off a respirator.
In Dr De Groot's series only 15% had computed tomographic scans. My question to Dr De Groot is, do you think if you could do computed tomographic scans on all these patients, you will see microabscesses throughout other portions of the lung? I think resecting these areas is important because you really only get one shot at curing these people.
I completely agree with the conclusion, however, that pulmonary resection plays an important role in the treatment of MDR-TB.
DR A. ALAN CONLAN (Worcester, MA): I congratulate Dr De Groot and his colleagues at the University of Cape Town for a very fine paper. Doctor Pomerantz has already covered some of my questions. I just wondered about residual disease in the patients who relapsed, and I wanted Dr De Groot to comment on the future use of high-resolution computed tomographic scan.
His pneumonectomy rate is very high and his bronchopleural fistula rate is very credible. I wanted to ask him how he handled the bronchial stump.
And finally, I wanted to ask him if patients with bilateral disease are ever surgical candidates.
DR HERBERT E. WARDEN (Morgantown, WV): In the past, when resectional therapy for pulmonary tuberculosis was more common, the development of a bronchopleural fistula was often secondary to the presence of endobronchial disease. Was this a factor in your patients with this complication?
You are to be complimented on your presentation of a very nice paper.
DR DE GROOT: I thank the discussants and particularly thank Dr Pomerantz; his expertise in the field is well known.
Starting from the back forward, in 10 years of dealing with patients with tuberculosis, and we see more than 200 to 300 cases a year, interestingly enough I have yet to see an overt case of endobronchial tuberculosis. It seems quite remarkable. It is a predisposition for fistula. We do perform bronchoscopy in our patients and have not seen endobronchial tuberculosis.
For Dr Conlan's question regarding whether high-resolution computed tomographic scan would lead to perhaps a higher yield of areas, we are not actually sure where the bacterium actually lives and is protected. To this end, we are embarking on a project, as I speak, of taking lungs from patients with active tuberculosis who have been operated on and looking at specimens with ordinary microbiological techniques as well as looking at frozen sections with confocal laser microscopy to see where the reservoirs of bacteria are.
As far as computed tomographic scans in general, our objective has always been to resect the macrocavitation. Any time that we have done computed tomographic scans in our patients, it actually just stands to scare us, because you often see more than you would ever imagine on a plain chest roentgenogram. Patients with tuberculosis have multifocal disease. There is really no way that we can effectively clear out all the small areas of scarring and nodularity.
As far as bilateral disease, there was 1 patient in whom we were considering doing bilateral staged apical resections for a bulla, but we did not undertake operation in that patient as he had converted to a sputum-negative status.
As to how we manage our bronchial stump, we do not do anything special. We avoid diathermy. We think the stump should be cleanly cut. We staple it with the least trauma possible and cover it with a pleural patch. We have not found the need for using any special form of muscle flap coverage.
Related Article
Ann. Thorac. Surg. 1997 63: 1368-1372.
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